Dr Robin Yeoh, I'm Dizzy Doc - St Anthony's Hospital

“I’m dizzy, doctor…”Robin YeohConsultant audiovestibular physicianSt Anthony’s Hospital20 April 2013

VertigoDefinition: sensation of imbalanceor disequilibrium with or withouta rotatory element.Site: may be central or peripheralIf peripheral – may be associatedwith other audiological features,namely hearing loss and tinnitus

VertigoIncidence of vertigo….40% will experience dizziness at least once inlifetime –incidence higher in women(National Institute of Health)

Vertigo

VertigoHistory taking• Pattern of attacks – frequency, time of day, prodrome• Duration - rarely more than hours if peripheral• Precipitating factors – movement, bed, aura• Relieving factors• Other associated features

VertigoInvestigations• Biochemical• ENG/Caloric testing• Imaging

VertigoExamination of the dizzy patientComprehensive history – remember other audiologicalsymptomsExamination –otoscopycranial nervescerebellar functioneye movementstests of posture and gaitthe Dix-Hallpike manoeuvre

VertigoPeripheral causes• Usually short-lived, no more than hours and often witha rotatory element.• May also have hearing loss, tinnitus and otheraudiological symptoms• Includes– Meniere’s disease (endolymphatic hydrops)– Benign Paroxysmal Positional Vertigo (BPPV)– Labyrinthitis/vestibular neuritis– Vestibular neuropathy– Perilymph fistula– Decompensation

VertigoMeniere’s diseaseA difficult clinical diagnosis,but should include lowfrequency sensorineuralhearing loss, tinnitus(usually described asroaring or rushing), andsudden acute rotatoryvertigo. May also havefullness of the ear

Vertigo

VertigoBenign Paroxysmal Positional Vertigoone of the commonest causes of imbalancehas a typical history and can often be diagnosed from itduration is relatively short-livedMx - conventional vestibular retrainingthe Epley manoeuvreother manoeuvres

VertigoCentral causes• Usually without true vertigo, nausea or vomiting• Other audiological symptoms absent• Non-specific symptoms including light-headedness, fainting, visualdisturbances, unsteadiness, etc etc• Includes– V vascular causes (migraine, stroke, VBI, hypotension,hyperventilation, anaemia– E epilepsy– R drug treatment– T tumour– I infections– G glial disease (MS)– O ocular disturbance

Commonest causes of “dizziness”• Labyrinthitis/vestibular neuronitis• Meniere’s disease• Benign paroxysmal positional vertigo• Migranous vertigo/brainstem migraine/migraine vestibularbalance disorder• Non-vestibular causes –• Hypotension• Anxiety/panic attacks• Vertebrobasilar insufficiency• Visual disturbance

VertigoManagement•Treat the treatable – polypharmacy?•Peripheral disorders are more likely to be self-limiting,therefore reassurance and watchful waiting•Use labyrinthine sedatives judiciously•Follow Kenny Roger’s advice….“Know when to stand, know when to fold…”

Questions?

Vertigo

Vertigo

Vertigo

Female 28 yr old c/o dizziness• Questions?• What does she mean by dizziness?• When did this arise?• Provocative features?• Relieving features?• Other symptoms – audio/oto/neuro/endo?• Relevant family history• Other relevant past history

Female 28 yr old c/o dizziness (II)• Examination• Ears• Nystagmus/Saccades/Smooth pursuit• Cranial nerves/cerebellar function• Other balance tests• Tests of posture and gait• Positioning tests

Female 28 yr old c/o dizziness (III)• Investigations• Audiometry – why?• Balance tests –• electronystagmography/• Dix Hallpike caloric test• Tests of posture – posturography• Other investigations

Female 28 yr old c/o dizziness (IV)• Diagnosis and Management